Transcript Faints, fits and funny turns - Trent Occupational Medicine

Faints, fits and funny turns
Dr Dominic Heaney
Consultant Neurologist and Honorary Senior Lecturer
National Hospital for Neurology and Neurosurgery
Queen Square
1 October 2013
Aims of presentation
• Faints, fits and funny turns
– Definitions
• Epilepsy
– Epidemiology, morbidity, mortality
– Types of seizures
– Treatment
• Neurologist’s view about epilepsy at work
Faints, fits, funny turns
• Transient alteration in awareness, consciousness
– Usually poorly described by patient
– Poorly witnessed
– Uncertainty
• “Faints, fits, funny turns” –
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Syncope (vasovagal, cardiogenic, other…)
Migraine
Cerebrovascular events
Epileptic seizure
Funny turns..
What a neurologist doesn’t want to
miss
What a neurologist doesn’t want to
see
Morbidity of Epilepsy
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Concurrent illness increased
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Neoplasms
Respiratory infections
Cardiovascular diesease
Depression
Sleep disorders
Osteoporosis/fractures
Accidents increased
• Drowning
• Suicide
• Accidental injury
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High psycho-social morbidity
• Unemployment
• Deprivation
Mortality of Epilepsy
• Mortality is 2 - 3x that of the general
population
– Standardised Mortality Rates
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Overall:
2-3
In the first 5 years: 4 - 5
20 - 40 years old
Chronic epilepsy:
5-8
8 - 15
• Proportional Mortality Rates
– neoplasms, respiratory, accidents, epilepsy
Mortality of epilepsy
• Epilepsy as the cause of death
• status epilepticus
• Sudep
– SUDEP
• > 600 cases a year in the UK
• aetiology unknown
• risk factors seem to be related to severity and
frequency of seizures
Epileptic seizures vs Epilepsy vs
Cause
• Seizure – type, anatomy
• Epilepsy syndrome – other symptoms, age,
EEG
• Aetiology – genetic, other
Classification of Seizures
Generalised
Focal
“epilepsy
Seizure classification
(International League Against
Epilepsy)
Partial
Simple partial
Complex partial
Secondary generalised
Generalised
Absence
Myoclonic
Atonic
Tonic
Tonic clonic
Determining seizure type
Clinical features
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Symptoms
Behavioural manifestations during and after
seizure
Witness account
focal
discharge
EEG
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Inter-ictal
Ictal
generalised
discharge
Generalised tonic-clonic seizure
•loss of consciousness
•‘epileptic cry’
•fall (injury)
•tonic phase then clonic
jerking
•tongue biting,
incontinence, cyanosis
•sudden onset, gradual
recovery
•post-ictal confusion,
sleep,
•headache, muscle pain
• aura/partial features if
SGS
Generalised absence seizure
• blank stare
• loss of consciousness
• cessation of motor activity
• blinking, eye rolling, minor tone change
• sudden onset, rapid recovery
• brief, many attacks per day
• usually in IGE
• generalised spike and wave discharge
Myoclonic jerks
• brief jerk, single or cluster
• one muscle → generalised jerks
• intensity: slight tremor → massive jerks
• consciousness probably preserved
• IGE (diurnal pattern)
• symptomatic epilepsies with other
seizure types + neurological deficit
• generalised spike and polyspike wave
Juvenile myoclonic epilepsy
Simple partial seizures
• no alteration in consciousness
• no amnesia
• sudden onset and cessation
• focal symptoms or signs:
affective,
motor
sensory and special sensory
psychic (dysmnestic, cognitive,
hallucinations, illusions)
• reflect anatomical origin of the seizure
• due to focal cortical pathology
Complex partial seizures
• Temporal lobe 60%
• Extra-temporal 40%
(mostly frontal lobe)
Complex partial seizure arising from
temporal lobe
• aura (as SPS: visceral, dysmnestic), brief
• altered consciousness
• amnesia
• automatism (oro-alimentary, gestural, verbal)
• sudden onset, gradual recovery
focal spikes
rhythmic ictal discharge
Frontal lobe CPS
• brief stereotyped seizures
• frequent attacks with clustering
• nocturnal +
• sudden onset and cessation
• complex bilateral motor automatisms
• secondary generalisation
• interictal and ictal EEG variable
Other extra-temporal partial seizures
Central
Parietal
Occipital
Contralateral jerks (march)
Contralateral sensory
Posturing
EEG often normal
Somatosensory
Illusion of change in body size/shape
Vertigo
Gustatory
Elementary visual hallucinations
Visuo-spatial distortion
Amaurosis
Head turning (usually adversive)
Eyelid flutter, blinking, nystagmus
May propagate to adjacent
cortical regions
EEG : focal / non-localised /
anterior
Investigation 1
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History + witnessed account
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Family history
History of meningitis/head injuries/febrile
convulsions
Alcohol and drug history
30% not epilepsy in tertiary referral clinic
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Syncopal jerking
Non-epileptic seizures with a pyschological
basis
Psychogenic seizures
Epilepsy
Non-epileptic
Emotion
Rare
Common
Onset
Rapid
Gradual
Aura
Various
Panic, confusion
Vocalisation
Various
Tears, crying
Consciousness
Complete/incompl
ete
Unresponsive but
normal alpha
Movements
Flailing, pelvic
Injury
Tongue bite, fall
Occasional
Incontinence
Common
Sometimes
Duration
Few mins
Long, variable
Investigation
• EEG
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at least 1% false positive
repeat and sleep - still 20% false negative
24 ambulatory EEG – increases yield
Video-telemetry
• Imaging
– MRI preferred to CT
• partial epilepsy, refractory epilepsy, neurological deficit
• Other
– ECG, FBC, U&E, LFT etc.
Bromide of potassium
for “hysterical epilepsy”
– curing 13 of 14 cases
Sir Charles Locock (1799-1875)
Obstetrician to Queen Victoria
Side effects
• By 1870’s 2.5 tons of bromide used every year
at the National Hospital, Queen Square
– “As you see he is broken down in appearance, has
large abscesses in his neck, and is altogether in a
bad condition. But this is better than to have
epilepsy”
An introduction to dermatology (1905) Bromide Rash
AED
Year available
Monotherapy licence
Phenobarbital
1912
Yes
Phenytoin
1938
Yes
Primidone
1952
Yes
Ethosuximide
1953
Yes
Carbamazepine
1963
Pre-1990
Diazepam
1965
No
Valproate
1973
Pre-1990
Clonazepam
1975
No
Clobazam
1986
No
(Vigabatrin)*
1989
No
Lamotrigine
1991
1995
Gabapentin
1993
Yes - rarely used
(Felbamate)*
1993
No
Topiramate
1995
Yes
Tiagabine
1998
No
Oxcarbazepine
2000
Yes
Levetiracetam
2000
Yes
Pregabalin
2004
No
Zonisamide
2005
Yes
Rufinamide
2007
No
Lacosamide
2008
No
Eslicarbazepine
2009
No
Retigabine
2011
No
Premapanel
2012
No
AED
Year available
Monotherapy licence
Tiagabine
1998
No
Oxcarbazepine
2000
Yes
Levetiracetam
2000
Post-2005
Pregabalin
2004
No
Zonisamide
2005
No
Rufinamide
2007
No
Lacosamide
2008
No
Eslicarbazepine
2009
No
Retigabine
2011
No
Premapanel
2012
No
AED
Year available
Monotherapy licence
Tiagabine
1998
No
Oxcarbazepine
2000
Yes
Levetiracetam
2000
Yes
Pregabalin
2004
No
Zonisamide
2005
Yes
Rufinamide
2007
No
Lacosamide
2008
No
Eslicarbazepine
2009
No
Retigabine
2011
No
Premapanel
2012
No
ZON
Weight
Mood
Cognition
Cardiac
Cosmetic
OD/BD/TDS
DDI
Teratogenicity
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On formulary?
Gp to Px?
Efficacy?
TOP
LAC
PGB
RTG
PMP
Formulary ‘management’
Drugs for seizures
• First-choice
– Partial onset: LTG, CBZ, LEV, (OXC)
– Generalised onset: VPA, LEV, LTG
• Adjunctive
– TOP, ZON, LAC
– PHT, PB, CLOB
– PGB, TIA,
Refractory epilepsy
• 20-30% of patients with epilepsy
• very few of these patients (5-10%) are suitable
for epilepsy neurosurgery
• Recently launched AEDs, render possibly less
than 2% of this group seizure free
Epilepsy in the workplace
• Challenges finding a job
– Lack of training, skills, on-the-job experience
– Lack of transportation
– Negative attitude of employers towards epilepsy
• Concerns about safety, liability, effectiveness, “crazy”,
customer view
– Negative attitudes of co-workers
Considerations in the workplace:
• The epilepsy:
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What type of epilepsy and what type of seizures?
Frequency, severity, duration?
Warning?
Call an ambulance?
Recovery period?
Triggers? (e.g. shift work, long shifts, stress, ??photosensitivity)
Medication
• The job:
– Equipment, heights, water, other?
– Working alone?
– Responsible for vulnerable individuals?
Reasonable adjustment
• making their workspace safer in case they have a
seizure
• avoiding lone working, so that someone else can
help if they have a seizure
• exchanging some tasks of the job with another
employee’s tasks
• adapting or providing equipment or support to
help them do their job
• time off for medical appointments that is
separate from sick leave.
Conclusions
• Not all seizures are due to epilepsy
• Epilepsy is a broad description given to a
range of conditions